Foot/Ankle Flashcards
What are common foot deformity? (6)
- Pas planus
- Pes Cavus
- Hallux Valgus
- Hammer toe
- Claw toe
- Mallet toe.
What ligaments are involved in a syndesmotic ankle sprain? (3)
1Anterior tibiofibular ligament,
2 posterior inferior tibiofibular ligament,
3 Syndesmosis of tibia and fibula. Deltoid ligament may be involved.
What is the mechanism of injury of a syndesmotic ankle sprain?
1DF of the ankle and external rotation of the tibia on a plant a foot.
2 Other MOI excessive IV and excessive DF.
How to diagnose a syndesmotic ankle sprain? (5)
1.MOI
2 pain with forced DF
3 pain with passive foot external rotation relative to foot
4 special tests
5.Pain out of proportion two apparent injury
What are the risk factors for developing plantar fasciitis? (4)
- Ages 45 and 65 years old
- overweight
- limited ankle DF
- occupation or leisure activity that requires prolong standing
Key diagnostic examination tests for patients with plantar fasciitis? (6)
- H/x of medial plantar heel pain-w/ initial weight-bearing following prolong inactivity and extended periods of weight-bearing activity
- pain with palpation of calcaneal plantar fasciitis
- active and passive DF ROM
- winless test
- Foot posture assessment
- body mass index
Differential diagnosis of plantar fasciitis? (9)
- Calcaneus stress fracture or bone bruise
- proximal plantar fibroma
- fat pad atrophy
- Tarsal tunnel syndrome
- soft tissue primary or metastatic bone tumor
- Paget disease
- Sievers disease
- Spondyloarthritis
- referred pain from S1
What is hammer toe?
- IP flexion deformity of one or two toes.
2. Second toe is commonly involved due to it being longer.
What is claw toe?
- Both IP flexion and MPT extension.
2. Claw toe present in all toes and caused by neuromuscular disease
What is Mallet toe?(3)
- Abnormal flexion of DIP can occur in isolation or secondary to hammertoe.
- Most frequently occurs at second toe.
- Cause from poorly fitting shoes
What two mechanisms contribute to pain after a high syndesmotic ankle sprain?
- Tibiofibular Joint loses stability
- Widening of ankle morties increase contact pressure to joint Resulting in diminished effectiveness of ankle plantar flexors
- Increase width of trochlea, during DF, joint may experience “gapping.”
- Strain on the healing ligaments as a result of excessive DF or instability during PF may result in pain.
What long-term problems can result from a lateral ankle sprain?(8)
- Persistent pain
- instability
- recurrent injury post
- traumatic arthritis
20-40% evolve into complex cases 1.Chondral damage 2.peroneal tendon damage 3Anterior impingement syndrome 4chronic ankle instability
How many bone in the foot? Grouped?(4)
- 28 bones in the foot
- 7 tarsal bones, 5 metatarsal, 14 phalanges, 2 sesamoid bones
- Hind foot-calcaneus and talus
Midfoot-navicular, cuboid, cuneiform
Forefoot-metatarsal and phalanges
What forms that talocrural joint?(3)
- Distal Tibia and fibula
2. Trochlea of talus
What ligaments support the ankle laterally? (2)
Anterior talofibular ligament and calcaneofibular ligament
What does the ATFL prevent?
Anterior displacement of Talus relative to ankle mortise.
If a patient reports a tumatic incident resulting in either forced inversion or eversion, what is differential diagnosis? (3)
- Possible ankle sprain
- Possible fracture
- Possible Peroneal nerve involvement-if MOI IV
If a patient reports pain or paresthesias in the plantar surface of the foot, what is differential diagnosis?(3)
- Possible tarsal tunnel syndrome
- Possible sciatica
- lumbar radiculopathy
What does calcaneofibular ligament do?
Limits ankle inversion
What are the Ottawa ankle rules?(3)
If any present below, radiographs are necessary.
1.Bone tenderness in the malleolar zone-along the medial and lateral malleoli Talar neck/head
2.Bone tenderness specifically at:
-Posterior edge or tip of lateral malleolus
—Posterior edge or tip of medial malleolus
—-Base of the fifth metatarsal
——Navicular
3.Inability to weight bear immediately following the injury and during exam
What is cuboid syndrome?(6)
- Lateral midfoot pain
- MOI-PF and IV ankle sprains
- 4% all foot injuries but 17% in professional ballet dancers
- Antalgic gait-pain with push off
- Decreased ankle ROM and painful/weak IV and EV
- Treatment manipulation of cuboid
What muscles are innervated by the tibial nerve?(7)
- Soleus
- Plantaris
- Popliteus
- Tibialis posterior
- Flexor Digitorum
- Flexor Hallucis Longus
- Gastrocnemius
What muscles are innervated by the deep peroneal nerve?(5)
- Tibialis Anterior
- Extensor Digitorum Longus
- Extensor Hallucis Longus
- Fibularis Tertius
- Extensor Digitorum Brevis
What muscles are innervated by the superficial peroneal nerve?(2)
- Peroneus Longus
2. Peroneus Brevis
Lisfranc injury staging?(4)
I. No separation between 1st and 2nd metatarsals or arch height
II. 1-5mm separation between 1st and 2nd metatarsals, but no arch height loss
III. >5mm separation between 1st and 2nd metatarsals, and loss of arch height
—For II and III need surgical fixation, typically 8 weeks NWB
Posterior Tibial Tendon Dysfunction staging?(4)
I.) TTP and swelling with pain during heel raise
II.) Flat foot presentation with rear foot eversion
Foot flat posture is flexible.
III.) Now flatfoot posture is more pronounced and no longer flexible
IV.) Same as above but now signs of ankle OA
Criteria for Wells DVT CPR?(8)
1,Active Cancer
- Paralysis or immobilization of the LE
- Bedridden in past 3 days or major surgery in the past 12 months
- TTP venous distribution of the leg
- 3cm increase in calf swelling measured below tibial tuberosity
- Pitting edema on suspected LE
- Collateral superficial veins
- Hx of DVT
Risk factors for Achilles tendinopathy?(2)
- Most common 41-60 years old
2. Obesity
Intrinsic risk factors for Achilles tendinopathy?(6)
Extrinsic factors?(2)
- Limited DF ROM
- Abnormal subtalar ROM
- Decreased PF strength
- foot pronation
- Abnormal tendon structure.
- Co-morbidities (obesity,hypertension increase cholesterol and diabetes)
Training errors
- Excessive mileage or increase mileage to quickly(Runners)
- Volleyball players with toe landing strategy
What is the single best predictor of plantar fasciitis?
Ankle DF limitation (0 Deg or less)
What is Os Trigonum?(3)
1.Accessory bone that develops behind the talus
2 Can cause posterior impingement in maximal PF.
3.Congenital and often affects dancers.
How is Medial Tibial Stress Syndrome differentiated from Compartment Syndrome? (2)
1.Compartment Syndrome is often associated with tibial n. paresthesia and pain that does not subside when activity is stopped.
What muscles are innervated by Medial Plantar Nerve?(4)
- Abductor Hallucis
- Flexor Digitorum Brevis
- 1st Lumbrical
- Flexor Hallucis Brevis
What levels of evidence for treatments and modalities for ankle ligament sprains?(4)
- Level A-Ice, ankle supports, therapeutic exercise, NO ULTRASOUND acutely, joint mobilization to improve DF
- Level B-Manual therapy such as soft tissue mobilization
- Level C-Diathermy for edema
- Level D-Electrotherapy and Laser
What is Baxter’s nerve entrapment?
1.Lateral plantar N. is impinged in the medal
heel.
2.Often diagnosed as plantar fasciitis.
3.May find weakness in abductor digiti minimi
What are some of the known impairments associated with ankle sprain? (9)
(1) Ankle and foot swelling,
(2) anterior instability of the talocrural joint and inversion laxity of the subtalar joint,
(3) medial joint line pain,
(4) decreases in ankle dorsiflexion ROM,
(5) decreased ankle and lower limb strength-ankle strength and global weakness in the lower extremity
(6) changes in peroneal recruitment/reaction time,
(7) decreased kinesthesia and/or proprioception,
(8) balance
a. decreased single limb stance,
b. dynamic balance using the Star Excursion Balance
Test, and
c. Balance Error Scoring System,
(9) functional Tests such as the lateral hop and figure-of-8 and hop test.
A current clinical practice guideline suggests the following indicate a high risk of reinjury for ankle sprain?(5)
(1) history of previous ankle sprain,
(2) failure to use external supports,
(3) failure to warm up with static stretching and dynamic
movement before activity,
(4) lacking normal ankle dorsiflexion range of movement, and
(5) failure to participate in a balance and proprioceptive
prevention program after a previous injury.
What is a tarsal coalition (TC)?(5)
- Rare, affecting less than 1% of patients with foot problems
- Afibrous, cartilaginous, or osseous fusion of two or more bones in the midfoot and hindfoot.
- Most common calcaneonavicular and middle facet talocalcaneal coalition
- Adolescents (between ages of 12-16)
- Adults- after trauma, surgery, or arthritis.
Clinical presentation of tarsal coalition (TC)?(6)
1.Adolescent with family history of TC
2.Repeated ankle sprains
3.Vague hindfoot pain (worse w/ activity and relieved w/ rest)
4.Tenderness over the sinus tarsi (for
Pts w/ calcaneonavicular coalition) sustentaculum tali (for pts w/ middle facet talocalcaneal coalition)
5.Pts frequently present with hindfoot valgus
6.Limited subtalar movement
Treatments of tarsal coalition (TC)(3)
Conservative
- activity modification/limitation,
- orthotics (medial heel wedge, arch supports), or
- antiinflammatory drugs.
Conservative fails
1.Cast immobilization for 4 to 6 weeks can reduce stress on jointsin the foot and allow microfractures to heal
Where does non-insertional Achilles tendinopathy occur?
Where does insertional Achilles tendinopathy occur?
- Approximately 6cm proximal to the insertion
2. Occurs at or near origin of the Achilles tendon
What are typical exam findings for insertional Achilles tendinopathy?(5)
- Swelling within 2cm of bone insertion
- Tenderness to pressure and stiffness at inseration
- Enlarged tendon
- Haglund Deformity.
- Abnormal shoe wear
What are clinical tests that are used to diagnose non-insertional Achilles tendinopathy?(3)
Symptoms of non-insertional Achilles tendinopathy?(2)
- Palpation
- Royals London Hospital test-
- Arch sign
- Intermittent pain related to exercise or activity
- Stiffness upon weight-bearing after prolong immobility, such as sleeping
What is the leading cause of foot flat deformity?
Posterior tibial tendon dysfunction
What type of braces or orthotics are recommended for PTTD? Stage?
Stage II
- Off the shelf or custom brace
- Controls hind foot eversion and inversion and supports the medial longitudinal arch
- Hinge ankle designed to prevent weakness
Stage III-IV
1.A solid ankle design is preferable
